This invention relates to a health insurance management system, and more particularly to a method and apparatus for processing health insurance claims using a computer program.
In the past, health insurance was almost exclusively the province of insurance companies which would issue a traditional reimbursement for services under a single set of master policy criteria. Recently, rising health care costs have driven many employers to become self-insured, leading to a proliferation of policy types, multiple coverage (accelerated by dual wage earner families) and wide variations in reimbursement and payment practices. However, self-insurers who are not in the insurance business are burdened by the administrative tasks associated with the processing of health insurance claims. This has caused the birth of a new industry devoted to assisting self-insurers in insurance-related administrative tasks. In addition to management companies specializing in this area, the insurance companies themselves have begun administering self-insurance plans for clients on a fee basis. Presently, more than half of all claims adjudicated by insurance companies (over $30 billion) were processed as the administrator of self-insured plans on a fee basis.
Management and insurance companies devoted to servicing a number of self-insurers must keep track of the different policies in effect at each client self-insurer company, the insured parties for each self-insurer, the claims filed for each individual within each client company, etc., so that when a claim is filed it can be processed correctly and efficiently. The greater the efficiency of the processing system, the greater will be the cost-effectiveness of the management company; greater cost-effectiveness in turn makes self-insurance administration more competitive relative to the services traditionally offered by the insurance companies.
As the volume of their business has increased, many insurance management companies have begun using computerized systems to more efficiently and quickly handle health insurance claims for their clients. However, the systems now in effect are of limited efficiency, in part because they require a great deal of input from human operators each time a claim is processed.